Release of Prior Empl Oyer Information Form 49 CFR Part 40 Drug and Alcohol Testing

Release of Prior Employer Information Form -- 49 CFR Part 40 Drug and Alcohol Testing

Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous employer:

Employee Printed or Typed Name: ______Employee SS or ID Number: ______

I hereby authorize release of information from my U.S. Department of Transportation (USDOT) regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with USDOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II-A by my previous employer, is limited to the following USDOT-regulated testing items:

1. Alcohol tests with a result of 0.04 or higher;

2. Verified positive drug tests;

3. Refusals to be tested;

4. Other violations of USDOT agency drug and alcohol testing regulations;

5. Information obtained from previous employers of a drug and alcohol rule violation;

6. Documentation, if any, of completion of the return-to-duty process following a rule violation.

Employee Signature: ______Date: ______

New Employer Name: ______Address: ______Phone #: ______Fax #: ______Designated Employer Representative: ______

Previous Employer Name: ______Address: ______Phone #: ______Designated Employer Representative (if known): ______

Section II. To be completed by the previous employer and transmitted by mail or fax to the new employer in I-A:

II-A. In the two (2) years prior to the date of the employee’s signature (in Section I), for USDOT-regulated testing, did the employee perform DOT defined safety-sensitive work for your organization? YES ____ NO ____ If yes, did the following situations ever occur during the time the employee worked for your organization? :

1. Did the employee have alcohol test(s) with a result of 0.04 or higher? YES ____ NO ____

2. Did the employee have verified positive drug test(s)? YES ____ NO ____

3. Did the employee refuse to be tested? YES ____ NO ____

4. Did the employee have other violations of USDOT agency drug and alcohol testing regulations? YES ____ NO ____

5. Did a previous employer report a drug and alcohol rule violation to you? YES ____ NO ____

6. If you answered “yes” to any of the above items, did the employee complete the return-to-duty process?

N/A ____ YES ____ NO ____

NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report. If you answered “yes” to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).

Name of person providing information in Section II-A: ______

Title: ______Phone #: ______Date: ______